A Technological Approach: Virtual Reality Exposure Therapy

Abstract

The use of virtual reality in the field of mental health is based on the change of human perceptions with artificial objects and places as if they exist in reality through computerized models. Virtual reality exposure therapy emerges as a preferred method because of being safe, economic and controllable. On the other hand, the difficulty of developing virtual reality applications, high cost of the virtual reality hardware systems, and possible side effects of virtual reality causes some limitations. Virtual reality applications for children started relatively late because of these side effects. This review article includes studies conducted with both adults and children. This article aims to explain what virtual reality therapy is and how it has been used in the process of counseling specific phobias, agoraphobia, posttraumatic stress disorder, obsessive compulsive disorder, attention deficit disorder, and autism. Subsequently, virtual reality applications were evaluated in terms of effectiveness, benefits, potential harmful aspects, and limitations.

Keywords

• Virtual reality
• Virtual reality exposure therapy
• Virtual reality therapy

Teknolojik Bir Yaklaşım: Sanal Gerçeklik Maruz Bırakma Terapisi

Abstract

Sanal gerçekliğin ruh sağlığı alanında kullanımı, bilgisayarlı modeller yoluyla insan algılarının yapay nesne ve yerlerle gerçekte varmışçasına değiştirilmesine dayalıdır. Sanal gerçeklik maruz bırakma terapisi, güvenli, ekonomik ve kontrol edilebilir bir yöntem olması nedeniyle tercih edilmektedir. Diğer yandan sanal gerçeklik uygulamalarının geliştirilmesinin karmaşıklığı, kullanılan donanımların yüksek maliyetli olması ve sanal gerçeklik kullanımının neden olduğu olası yan etkiler, bazı sınırlılıklara neden olmaktadır. Bu yan etkiler, özellikle çocuklarla yapılan sanal gerçeklik uygulamalarının görece daha geç başlamasına neden olmuştur. Bu derleme makalesi kapsamında hem yetişkinlerle hem de çocuklarla yürütülen çalışmalara yer verilmektedir. Bu makalede ilk olarak sanal gerçeklik maruz bırakma terapisinin ne olduğu açıklanmış, ardından sanal gerçeklik terapisi ile sıklıkla çalışılmış olan özgül fobiler, kapalı alan ve açık alan korkusu, sosyal fobi, travma sonrası stres bozukluğu, obsesif kompulsif bozukluk, dikkat eksikliği ve hiperaktivite bozukluğu ile otizmde kullanılan sanal gerçeklik temelli uygulamalar ele alınmıştır. Daha sonra sanal gerçeklik uygulamaları, etkililikleri, yararları, olası zararları ve sınırlılıkları açısından değerlendirilmiştir.

Keywords

• Sanal gerçeklik
• Sanal gerçeklik maruz bırakma terapisi
• Sanal gerçeklik terapisi

References

1. Abdullah, M., & Shaikh, Z. A. (2018). An effective virtual reality-based remedy for acrophobia. International Journal of Advanced Computer Science and Applications, 9(6), 162-167. doi: 10.14569/IJACSA.2018.090623
2. Adams, R.,Finn, P., Moes, E., Flannery, K., & Rizzo, A. (2009). Distractibility in Attention Deficit Hyperactivity Disorder (ADHD): The virtual reality classroom. Child Neuropsychology, 15(2), 120-135. doi: 10.1080/09297040802169077
3. Akdeniz, S., Ahçı, Z., & Yumuşak, S. (2020). Sanal gerçeklik ve psikoterapide kullanımı. Karatay Sosyal Araştırmalar Dergisi, (4), 1-20.
4. American Psychological Association [APA]. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Washington DC: American Psychiatric Association.
5. Anderson, P. L., Zimand, E., Hodges, L. F., & Rothbaum, B. O. (2005) Cognitive behavioral therapy for public-speaking anxiety using virtual reality for exposure. Depression and Anxiety, 22(3), 156-8. doi: 10.1002/da.20090
6. Baker, J. B. (2008). Using computer-based MUVES to develop social skills in elementary children: An exploratory study. (Unpublished doctoral dissertation). Regent University, America.
7. Bayraktar, E. ve Kaleli, F. (2007, Şubat). Sanal gerçeklik ve uygulama alanları. Akademik Bilişim’07 - IX. Akademik Bilişim Konferansı, Kütahya.
8. Beidel, D. C., Frueh, B. C., Neer, S. M., Bowers, C. A., Trachik, B., Uhde, W., & Grubaugh, A. (2017). Trauma management therapy with virtual reality augmented exposure therapy for combat-related PTSD: A randomized controlled trial. Journal of Anxiety Disorders, 1-11. doi: 10.1016/j.janxdis.2017.08.005

9. Belloch, A., Cabedo, E., Carrió, C., Lozano-Quilis, J. A., Gil-Gómez, J. A., & Gil-Gómez, H. (2014). Virtual reality exposure for OCD: Is it feasible? Revista de Psicopatología y Psicología Clínica, 19, 37-44.
10. Botella, C., Banos, R. M., Perpina, C., Villa, H., Alcaniz, M., & Rey, A. (1998). Virtual reality treatment of claustrophobia: A case report. Behavior Research and Therapy, 36(2), 239-246. doi: 10.1016/S0005-7967(97)10006-7
11. Botella, C., Palacios, A., Villa, H., & Quero, S. (2004). The use of VR in the treatment of panic disorders and agoraphobia. Studies in Health Technology and Informatics, 99, 73-90.
12. Botella, C., Villa, H., Banos, R., Perpina, C., & Palacious, A. (1999). The treatment of claustroprohiba with virtual reality: Changes in other phobic behaviors not specifically treated. Cyber Psychology & Behavior, 2(2), 135-141. doi: 10.1089/cpb.1999.2.135
13. Bouchard, S., Cote, S., St-Jacques, J., Robillard, G., & Renaud, P. (2006). Effectiveness of virtual reality exposure in the treatment of anacarophobia using 3D games. Technology and Health Care,14(2006), 19-27.
14. Bozkurt, S. S. (2016). Otizm spektrum bozukluğu olan çocuklara sosyal beceri öğretiminde teknoloji destekli etkileşimli ortam tasarımı ve etkililiği. (Yayımlanmamış doktora tezi). Anadolu Üniversitesi, Eskişehir, Türkiye.
15. Bruce, M., & Regenbrecht, H. (2009). A virtual reality claustrophobia therapy system - implementation and test. In IEEE Virtual Reality Conference (pp. 19-25.), Washington: IEEE.
16. Cardoş, R. A. I., David, O. A., & David, D. O. (2018). Virtual reality exposure therapy in flight anxiety: A quantitative meta-analysis. Computers in Human Behavior, 72(2017). 371-380. doi: 10.1016/j.chb.2017.03.007
17. Chang, E., Kim, H. T., & Yoo, B. (2020). Virtual reality sickness: A review of causes and measurements. International Journal of Human-Computer Interaction, 36(17), 1658-1682. doi: 10.1080/10447318.2020.1778351
18. Costa, R. T., Carvalho, M. R., Ribeiro, P., & Nardi, A. E. (2010). Virtual reality exposure therapy in the treatment of driving phobia. Psicologia: Teoria e Pesquisa, 26(1), 131-137. doi: 10.1590/S0102-37722010000100015
19. Çelik, Z., Alptekin, F. B., & Yavuz, K. F. (2020). Acrophobia treatment with virtual reality assisted acceptance and commitment therapy: Case reports. Dusunen Adam The Journal of Psychiatry and Neurological Sciences, 33, 317-324. doi: 10.14744/DAJPNS.2020.00097
20. Demirci, Ş. (2018). Sağlık hizmetlerinde sanal gerçeklik teknolojileri. İnönü Üniversitesi Sağlık Hizmetleri Meslek Yüksekokulu Dergisi, 6(1), 35-46.
21. DeRosier, M. E., Craig, A. B., & Sanchez, R. P. (2012). ZooU: A stealth approach to social skills assessment in schools. Advances in Human-Computer Interaction, 25, 1-7. doi: 10.1155/2012/654791
22. Didehbani, N., Allen, T., Kandalaft, M. Krawczyk, D., & Chapman, S. (2016). Virtual reality social cognition training for children with high functioning autism. Computers in Human Behavior, 62, 703-711. doi: 10.1016/j.chb.2016.04.033
23. Difede, J., & Hoffmann, H. J. (2004). Virtual reality exposure therapy for world trade center post-traumatic stress disorder: A case report. CyberPscyhology & Behavior, 5(6), 529-535. doi: 10.1089/109493102321018169
24. Difede, J., Cukor, J., Jayasinghe, N., Patt, I., Jedel, S., Spielman, L., Giosan, C., & Hoffman, H. G. (2007). Virtual reality exposure therapy for the treatment of posttraumatic stress disorder. Clinical Psychiatry Journal, 68(11), 1639-1647.
25. Donker, T., Esveld, S. V., Fischer, N., & Straten, A. (2018). Phobia - towards a virtual cure for acrophobia: study protocol for a randomized controlled trial. Open Access,19(433), 1-11.
26. Emmelkamp, P. M. (2005). Technological innovations in clinical assessment and psychotherapy. Psychotherapy and Psychosomatics, 74(6), 336-343, doi: 10.1159/000087780
27. Emmelkamp, P. M., Krijn, M., Hulsbosch A. M., Vries, S., Schuemie, M. J., & Mast, C. A. (2002). Virtual reality treatment versus exposure in vivo: A comparative evaluation in acrophobia. Behaviour Research and Therapy, 40(2002), 509-516, doi: 10.1016/s0005-7967(01)00023-7
28. Fernandez-Alvarez, J., Rozental, A., Carlbring, P., Colombo, D., Riva, G., … Botella, C. (2018). Deterioration rates in virtual reality therapy: An individual patient data level meta-analysis. Journal of Anxiety Disorders, 35(7), 34-43. doi: 10.1016/j.janxdis.2018.06.005
29. Freeman, D., Haselton, P., Freeman, J., Spanlang, B., Kishore, S., Albery, E., Denne, M., Brown, P., Slater, M., & Nickless, A. (2018). Automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomized controlled trial. Lancet Psychiatry, 2018(5), 625-632, Doi: 10.1016/S2215-0366(18)30226-8
30. Gray, C. (2004). Social Stories 10.0: The new defining criteria and guidelines. The Jenison Autism Journal,16(1), 2-21.
31. Gutierrez, J. (2002). Aplicaciones de la relidad virtual en pcilogia clinica. Aula Medica Psiquiatria, 4(2), 92-126.
32. Herbelin, B. (2005). Virtual reality exposure therapy for social phobia. (Unpublished doctoral dissertation). Université Louis Pasteur, Strasbourg, France.
33. Herbert, J. D., Forman, E. M., Goetter, E. M., Corner, R., & Bradley, J. (2013). Treatment of social anxiety disorder using online virtual environments in second life. Behavior Therapy, 44(2013), 51-61. doi: 10.1016/j.beth.2012.06.001
34. Hirose, M., Kijima, R., Shirakawa, K., & Nihei, K. (1997). Development of a virtual sand box: An application of virtual environment for psychological treatment. Studies of Health Technology Information. 44, 113-120.
35. Işıklı, S., Baran, Z. ve Aslan, S. (2019). Özgül fobilerde sanal gerçeklik teknolojisi uygulamaları ile tedaviye yardımcı araç geliştirme: Bir etkililik çalışması. Klinik Psikiyatri, 22, 316-328. doi: 10.5505/kpd.2019.43660
36. İnözü, M., Çelikcan, U., Akın, B., & Mustafaoğlu-Çiçek, N. (2020). The use of virtual reality exposure for reducing contamination fear and disgust: Can VR be an effective alternative exposure technique to in vivo? Journal of Obsessive Compulsive and Related Disorders, 25, 1-8. doi: 10.1016/j.jocrd.2020.100518
37. Kampmann, I. L., Emmelkamp, P. M. G., & Morina, N. (2016). Meta-analysis of technology assisted interventions for social anxiety disorder. Journal of Anxiety Disorders. 42(2016), 71-84. doi: 10.1016/j.janxdis.2016.06.007
38. Ke, F., & Lee, S. (2016). Virtual reality based collaborative design by children with high-functioning autism: Design-based flexibility, identity, and norm construction. Interactive Learning Environments, 24(7), 1511-1533. doi: 10.1080/10494820.2015.1040421
39. Kim, K., Kim, C. H., Kim, S. Y., Roh, D., & Kim, S. (2009). Virtual reality for obsessive-compulsive disorder: Past and the future. Psychiatry Investigation, 6, 115-121. doi: 10.4306/pi.2009.6.3.115
40. Kim, K., Kim, C. H., Cha, K. R., Park, J., Han, K. & Kim, Y. K. (2008). Anxiety provocation and measurement using virtual reality in patients with obsessive-compulsive disorder. Cyberpsychology Behavior, 11, 637-641. doi: 10.1089/cpb.2008.0003
41. Kim, H. E., Hong, Y., Kim, M., Jung, Y. H., Kyeong, S., & Kim, J. (2017). Effectiveness of self-training using the mobile-based virtual reality program in patients with social anxiety disorder. Computers in Human Behavior, 73(2017), 614-619. doi: 10.1016/j.chb.2017.04.017
42. Klinger, E., Bouchard, S., Légeron, P., Roy, S., Lauer, F., & Chemin, I. (2005). Virtual reality therapy versus cognitive behavior therapy for social phobia: A preliminary controlled study. Cyberpsychology and Behavior, 8(1),76-88. doi: 10.1089/cpb.2005.8.76
43. Krijn, M., Emmelkamp, P. M. G., Biemond, R., Ligny, C., Schuemie, M. J., & Mast C. A. (2004). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behavior Therapy, 42, 229-239. doi: 10.1016/S0005-7967(03)00139-6
44. Laforest, M., Bouchard, S., Bosse, J., & Mesly, O. (2016). Effectiveness of in virtuo exposure and response prevention treatment using cognitive behavioral therapy for obsessive disorder: A study based on a single-case study protocol. Front Psychiatry, 13(7), 99. doi: 10.3389/fpsyt.2016.00099
45. Lorenzo, G., Lledo, A., Pomares, J., & Roig, R. (2016). Design and application of an immersive virtual reality system to enhace emotional skills for children with autism spectrum disorders. Computers and Education, 98, 192-205. doi: 10.1016/j.compedu.2016.03.018
46. Malbos, E., Mestre, D. R., Note, I. D., & Gellato, C. (2008). Virtual reality in claustrophobia: multiple components therapy involving game editor virtual environments exposure. Cyberpsychology and Behavior, 11, 695-697. doi: 10.1089/cpb.2007.0246
47. Maldonado, G. Z., Neri, E., Calafell, M., & Salazar, C. P. (2009). Virtual reality exposure therapy for school phobia. Anuario de Psicología, 40(2), 223-236.
48. Martin, H. V., Botella, C., Palcios, A., & Osma, J. (2007). Virtual reality exposure in the treatment of panic disorder with agoraphobia: A case study. Cognitive and Behavioral Practice,14(1), 58-69. doi: 10.1016/j.cbpra.2006.01.008
49. Martine, J. B., Kasanmoentalib, M. S., Koning, P. P., & Denys, D. (2017). A virtual reality game to assess obsessive compulsive disorder. Cyber psychology, Behavior and Social Networking, 20(11), 718-722. doi: 10.1089/cyber.2017.0107
50. North, M. M., North, S. M., & Coble, J. R. (1996). Virtual environment psychotherapy: A case study of fear of flying disorder. Teleoperators and Virtual Environments, 6(1), 127-132. doi: 10.1162/pres.1997.6.1.127North, M. M.,
51. North, S. M., & Coble, J. R. (1997a). Virtual reality therapy: An effective treatment for psychological disorders. In Riva G. (Ed.), Virtual Reality in Neuro-Psycho-Physiology (pp. 59-65). Amsterdam, Netherlands: Ios Press.
52. North, M. M., North, S. M., & Coble, J. R. (1997b). Virtual reality therapy for fear of flying. American Journal of Psychiatry,154(1), 130-130. doi: 10.1176/ajp.154.1.130b
53. Othmer, S., & Kaiser, D. (2000). Implementation of virtual reality in EEG biofeedback. Cyberpsychology & Behavior, 3(3), 415-420. doi: 10.1089/10949310050078878
54. Özer, Ö. ve Yöntem, M. K. (2019). Sosyal anksiyeteye müdahalede teknolojik bir araç: Sanal gerçeklik. Psikiyatri Hemşireliği Dergisi, 10(4), 296-301. doi: 10.14744/phd.2019.75010
55. Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: A controlled study. Behavior Research and Therapy, 40(9), 983-993. doi: 10.1016/s0005-7967(01)00068-7
56. Pardo, G. D., & Garcia, I. M. (2012). Virtual reality applications in attention deficit disorder with hyperactivity: An approximation. Annuary of Clinical and Health Psychology, 2012(8), 29-37. doi: 10.2147/NDT.S206742
57. Parrish, D. E., Oxhandler, E. K., Duron, J. F., Swank, P., & Bordnick, P. (2016). Feasibility of virtual reality environments for adolescent social anxiety disorder. Research on Social Work Practice, 26(7), 825-835. doi: 10.1177/1049731514568897
58. Parsons, S., Mitchell, P., & Leonard, A. (2004). The use and understanding of virtual environments by adolescents with autistic spectrum disorders. Journal of Autism and Developmental Disorders,34(4), 449-466. doi: 10.1023/B:JADD.0000037421.98517.8d
59. Parsons, T., & Rizzo, A. (2008). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 39, 250-261. doi: 10.1016/j.jbtep.2007.07.007
60. Parsons, T., Bowerly, T., Buckwalter, J. G., & Rizzo, A. (2007). A controlled clinical comparison of attention performance in children with ADHD in a virtual reality classroom compared to standard neuropsychological methods. Child Neuropsychology,13(4),363-381. doi: 10.1080/13825580600943473
61. Penate, W., Fuente, J., Bethencourt-Pere, J. M., Acosta, L., Villaverde, M. L., & Gracia, R. (2008). Agoraphobia: Combined treatment and virtual reality. Actas Esp Psiquiatr, 36(2), 94-101.
62. Powers, M. B., & Emmelkamp, P. M. G. (2008). Virtual reality exposure therapy for anxiety disorders: A meta-analysis. Journal of Anxiety Disorders, 22, 561-569. doi: 10.1016/j.janxdis.2007.04.006
63. Rachman, S., De Silva, P. (2009). Obsessive compulsive disorder (4th ed.), New York: Oxford University Press.
64. Rizzo, A. A., Buckwalter, T. B., Zaag, V., Humphrey, L., Neumann, U., Chua, C., Kyriakakis, A, Van Rooyen, A., & Sisemore, D. (2000). The virtual classroom: A virtual reality environment for the assessment and rehabilitation of attention deficits. Cyberpsychology & Behavior, 3(3), 21-32. doi: 10.1089/10949310050078940
65. Romano, D. M. (2005). Virtual reality therapy. Developmental Medicine and Child Neurology, 47, 580-580.
66. Rothbaum, B. O., Hodges, L. F., & Smith, S. (1999). Virtual reality exposure therapy abbreviated treatment manual: Fear of flying application. Cognitive and Behavioral Practice, 6, 234-244. doi: 10.1016/S1077-7229(99)80081-9
67. Rothbaum, B. O., Hodges, L. F., Ready, D., Graap, K., & Alarcon, R. D. (2001). Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder. The Journal of Clinical Psychiatry, 62(8), 617-622. doi: 10.4088/jcp.v62n0808
68. Rothbaum, B. O., Hodges, L., Watson, B. A., & Kessler, G. D. (1996). Virtual reality exposure therapy in the treatment of fear of flying: A case report. Behaviour Research and Therapy, 34(5), 477-481.
69. Rothbaum, B. O., Hoges, L., Alarcon, R., Shahar, F., Graap, K., Pair, J., Hebert, P., Gotz, D., Wills, B., & Baltzer, D. (1999). Virtual reality exposure therapy for PTSD Vietnam veterans: A case study. Journal of Traumatic Stress, 12(2), 262-271.
70. Rothbaum, B., Anderson, P., Zimand, E., Hodges, L., Lang, D., & Wilson, J. (2006). Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying. Behavior Therapy, 37, 80-90. doi: 10.1016/j.beth.2005.04.004
71. Rothbaum, B., Hodges, L., Kooper, R., Opdykes, D., Williford, J., & North, M. (1995). Effectiveness of computer-generated (virtual reality) graded exposure in the treatment of acrophobia. American Journal of Psychiatry, 152(4), 626-628.
72. Sarver, N. V., Beidel, D. C., & Spitalnick, J. S. (2014). The feasibility and acceptability of virtual environments in the treatment of childhood social anxiety disorder. Journal of Clinical Child and Adolescent Pscychology, 43(1), 63-73. doi: 10.1080/15374416.2013.843461
73. Schweitzer, T., Renner, F., Sun, D., Kleim, B., Holmes, E. A., & Tuschen-Caffier, B. (2018). Psychophysiological reactivity, coping behavior and intrusive memories upon multisensory Virtual Reality and Script Driven Imagery an alogue trauma: A randomized controlled crossover study. Journal of Anxiety Disorders, 59, 42-52. doi: 10.1016/j.janxdis.2018.08.005
74. Taffou, M., Guerchouche, R., Drettakis, G., & Viaud-Delmon, I. (2013). Auditory-visual aversive stimuli modul at the conscious experience of fear. Multisensory Research, 26(2013), 347-370.
75. Turan, C. (2015). Otizm spektrum bozukluğu gösteren çocuklara sosyal beceri öğretiminde sosyal öykü ve video model uygulamalarının etkililik ve verimlilikleri. (Yayımlanmamış doktora tezi). Anadolu Üniversitesi, Eskişehir, Türkiye.
76. Üzümcü, E., Akın, B., Nergiz, H., İnözü, M., & Çelikcan, U. (2018). Anksiyete bozukluklarında sanal gerçeklik. Psikiyatride Güncel Yaklaşımlar, 10(1), 99-117. doi: 10.18863/pgy.336593
77. Valmaggia, V. L., Latif, L., Kempton, M. J., & Rus-Calafell, M. (2016). Virtual reality in the psychological treatment for mental health problems: An systematic review of recent evidence. Pschiatry Research, 236, 189-195. doi: 10.1016/j.psychres.2016.01.015
78. Vardarlı, B. (2020). Çocuklar için sanal gerçeklik sosyal duygusal öğrenme becerileri eğitiminin tasarlanması ve etkililiğinin incelenmesi: Bir karma yöntem çalışması. (Yayımlanmamış doktora tezi). Ege Üniversitesi, İzmir, Türkiye.
79. Wald, J. (2004). Efficacy of virtual reality exposure therapy for driving phobia: A multiple baseline across-subjects design. Behavior Therapy, 35, 621-635.
80. Wiederhold, B. K., & Wiederhold, M. D. (2003). Using virtual reality psychotherapy in panic disorder with agoraphobia. Pschriatric Times, 20(7), 45-51.
81. Yan, N., Wang, J., Liu, M., Zong, L., Jiao, Y., Yue, J., Lv, Y., Yang, Q., Lan, H., & Liu, Z. (2008). Designing a brain computer interface device for neurofeedback using virtual environments. Journal of Medical and Biological Engineering, 28(3), 167-172.
82. Yıldız, B., Gül, E. ve Birçek, N. I. (2020). Bir sosyal fobi vakasında bilişsel davranışçı terapi ve sanal gerçeklik kombinasyonu. Bilişsel Davranışçı Psikoterapi ve Araştırmalar Dergisi, 9(2), 158-165. doi: 10.5455/JCBPR.61718